Contribution of genetic polymorphism of methylene tetrahydrofolate reductase on the effect of methotrexate in ectopic pregnancy patients.

BACKGROUND: Methotrexate (MTX) is the prior drug in ectopic pregnancy (EP). However, approximately 10% of patients suffer from failure by MTX therapy. Reduced folate carrier 1 (RFC1), methylene tetrahydrofolate reductase (MTHFR), and dihydrofolate reductase (DHFR) are involved in the transport and effects of MTX in vivo. In the present study, we aim to investigate the relationship between the genetic polymorphisms of RFC1, MTHFR, and DHFR and the clinical efficacy of MTX in tubal pregnancies. METHODS: 100 patients of EP were enrolled in this study. Polymorphisms of RFC1 G80A, MTHFR C677T, and DHFR A-317G were genotyped. ß-hCG level was detected in day 0, 4, and 7 after MTX injection. Association of MTX efficacy and genetic polymorphisms was analyzed. RESULTS: Methylene tetrahydrofolate reductase C677T was associated with MTX treatment (P = .017). The success rate of first MTX injection was superior in patients with harboring mutation allele of MTHFR gene than that in patients with wild-type gene (P = .001). However, there was no significant association between the polymorphisms of RFC1 G80A, DHFR A-317G, and surgical treatment (P = .709 and .476, respectively). In addition, ß-hCG level decrement was not significantly changed by MTX injection with different polymorphisms of RFC1, MTHFR, and DHFR on either day 4 (P = .214, 0.197 and 0.270, respectively) or day 7 (P = .172, .554, and .726, respectively). CONCLUSION: Our results suggested that the reliable indicator was polymorphism of MTHFR C677T in failure by MTX injection.

The regulation of nitric oxide synthase isoform expression in mouse and human fallopian tubes: potential insights for ectopic pregnancy.

Nitric oxide (NO) is highly unstable and has a half-life of seconds in buffer solutions. It is synthesized by NO-synthase (NOS), which has been found to exist in the following three isoforms: neuro nitric oxide synthase (nNOS), inducible nitric oxide synthase (iNOS), and endothelial nitric oxide synthase (eNOS). NOS activity is localized in the reproductive tracts of many species, although direct evidence for NOS isoforms in the Fallopian tubes of mice is still lacking. In the present study, we investigated the expression and regulation of NOS isoforms in the mouse and human Fallopian tubes during the estrous and menstrual cycles, respectively. We also measured isoform expression in humans with ectopic pregnancy and in mice treated with lipopolysaccharide (LPS). Our results confirmed the presence of different NOS isoforms in the mouse and human Fallopian tubes during different stages of the estrous and menstrual cycles and showed that iNOS expression increased in the Fallopian tubes of women with ectopic pregnancy and in LPS-treated mice. Elevated iNOS activity might influence ovulation, cilia beats, contractility, and embryo transportation in such a manner as to increase the risk of ectopic pregnancy. This study has provided morphological and molecular evidence that NOS isoforms are present and active in the human and mouse Fallopian tubes and suggests that iNOS might play an important role in both the reproductive cycle and infection-induced ectopic pregnancies.

Why does the fallopian tube fail in ectopic pregnancy? The role of activins, inducible nitric oxide synthase, and MUC1 in ectopic implantation.

OBJECTIVE: To investigate the role of activin-ßA subunit, activin type II receptors, inducible nitric oxide synthase (iNOS), and MUC1 in the pathogenesis of ectopic pregnancy (EP) and their involvement in the determination of the implantation site. DESIGN: Observational study. SETTING: Academic unit of reproductive and developmental medicine. PATIENT(S): Four women at the luteal phase, three pseudopregnant women at the time of hysterectomy for benign disease, and 10 archived cases of EP. We collected 14 Fallopian tubes were collected from four women at the luteal phase and three pseudopregnant women at the time of hysterectomy for benign disease; specimens from implantation site, trophoblast and remote sites from the implantation site were collected from 10 archived cases of EP. INTERVENTION(S): Immunohistochemistry and quantitative reverse-transcriptase polymerase chain reaction (RT-PCR). MAIN OUTCOME MEASURE(S): Comparison of the expression of candidate molecules between the different groups. RESULT(S): The expression of activin-ßA subunit, activin type II receptors, and iNOS was statistically significantly increased and expression of MUC1 statistically significantly decreased in tubes bearing an EP. There was no statistically significant difference in the expression of the candidate molecules between the implantation and remote sites. Candidate molecules were also expressed in the trophoblast. CONCLUSION(S): The pathological expression of candidate molecules by tubes bearing an EP is not involved in the determination of implantation site. Additionally, candidate molecules may play a role in the regulation of trophoblast cells in vivo during early pregnancy.

The role of CPK isoenzymes in predicting extrauterine early pregnancy.

OBJECTIVE: To evaluate the ability of Creatine phosphokinase (CPK) levels and CPK-MB proportion to differentiate between extra and intrauterine of very early gestations with unknown location. MATERIALS AND METHODS: The study is case-control. CPK levels and CPK-MB proportion in 51 women with extrauterine pregnancies were compared to those in 28 women with early intrauterine pregnancies. RESULTS: No significant difference was found between women with extrauterine pregnancies and early intrauterine pregnancies in the levels of CPK (80.9 ± 62.1 vs. 74.9 ± 51.5; p = 0.66) and CPK-MB proportion (16.2 ± 10.1% vs. 15.1 ± 11.1%; p = 0.86). CONCLUSION: CPK and CPK-MB proportion determinations do not contribute to the clinical differentiation between early intra and extrauterine pregnancies.

Nitric oxide synthases and tubal ectopic pregnancies induced by Chlamydia infection: basic and clinical insights.

Human ectopic pregnancy (EP) remains a common cause of pregnancy-related first trimester death. Nitric oxide (NO) is synthesized from L-arginine by three NO synthases (NOS) in different tissues, including the Fallopian tube. Studies of knockout mouse models have improved our understanding of the function of NOS isoforms in reproduction, but their roles and specific mechanisms in infection-induced tubal dysfunction have not been fully elucidated. Here, we provide an overview of the expression, regulation and possible function of NOS isoforms in the Fallopian tube, highlighting the effects of infection-induced changes in the tubal cellular microenvironment (imbalance of NO production) on tubal dysfunction and the potential involvement of NOS isoforms in tubal EP after Chlamydia trachomatis genital infection. The non-equivalent regulation of tubal NOS isoforms during the menstrual cycle suggests that endogenous ovarian steroid hormones regulate NOS in an isoform-specific manner. The current literature suggests that infection with C. trachomatis induces an inflammatory response that eventually leads to tubal epithelial destruction and functional impairment, caused by a high NO output mediated by inducible NOS (iNOS). Therefore, tissue-specific therapeutic approaches to suppress iNOS expression may help to prevent ectopic implantation in patients with prior C. trachomatis infection of the Fallopian tube.

The expression of inducible nitric oxide synthase in the human fallopian tube during the menstrual cycle and in ectopic pregnancy.

OBJECTIVE: To investigate the production of inducible nitric oxide synthase (iNOS) in the fallopian tube (FT) during the menstrual cycle and whether epithelia from FTs bearing an ectopic pregnancy differ from healthy tubes in iNOS expression. DESIGN: Prospective study. SETTING: Academic unit of reproductive and developmental medicine. PATIENT(S): Fallopian tubes from the different stages of the menstrual cycle (n=12), FTs bearing an ectopic pregnancy (n=15), and FTs from pseudopregnant women (n=6) were collected. INTERVENTION(S): In the pseudopregnant group, patients were injected with hCG in the days leading up to hysterectomy. Samples were processed for immunohistochemistry staining and quantitative reverse transcriptase polymerase chain reaction. MAIN OUTCOME MEASURE(S): To compare iNOS protein and messenger RNA expression between the different groups. RESULT(S): This is the first report on cyclicity in iNOS production by human fallopian tube during the menstrual cycle. The intensity of expression of iNOS was higher in the ectopic pregnancy group compared with the pseudopregnant group (P<0.05). CONCLUSION(S): The cyclicity in iNOS expression by the tube suggests its involvement in fertilization and early embryonic development. Pathologic generation of nitric oxide through increase iNOS production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy.

Cyclic and characteristic expression of phosphorylated Akt in human endometrium and decidual cells in vivo and in vitro.

BACKGROUND: Akt is activated by phosphorylation and plays an important role in cell survival and maintenance of structure. METHODS: We investigated whether phosphorylated Akt was characteristically expressed in human endometrium in vivo and whether insulin-like growth factor-I (IGF-I) can activate Akt using cultured decidualized human stromal cells in vitro, using immunohistochemistry and Western blotting analysis. RESULTS: The levels of phosphorylated Akt protein increased markedly in the decidual tissues from ectopic pregnancy. The expression of phosphorylated Akt protein in stromal cells increased with the decidualization. The decidual cells showed strong cytoplasmic staining for phosphorylated Akt. However, cultured decidualized human stromal cells diminished phosphorylated Akt expression compared to control cells. IGF-I administration to decidualized human stromal cells significantly recovered pAkt expression. The effect of IGF-I on decidualized human stromal cells was blocked by an inhibitor of phosphatidylinositol-3 kinase (PI3K) (LY294,002). These results suggest that IGF-I may activate Akt via PI3K in human endometrium and decidua. The expression of phosphorylated Akt in stromal cells was only detected in the functional layer, where tissue remodelling occurs during menstruation or implantation. CONCLUSIONS: Akt activation may be involved in cell survival and extracellular matrix remodelling in human endometrium and decidua.

Serum levels of myoglobin, creatine phosphokinase, and smooth muscle heavy-chain myosin in patients with ectopic pregnancy.

STUDY OBJECTIVE: Serum markers of smooth muscle destruction have been shown to be elevated in ectopic pregnancy, but they remain of questionable clinical utility. Our goal was to determine the clinical utility of 3 markers of smooth muscle destruction: creatine phosphokinase (CPK), smooth muscle heavy-chain myosin (SMHC), and myoglobin. METHODS: This was a prospective cohort study, with consecutive enrollment of all women in the first trimester of pregnancy who presented to our urban emergency department with complaints of lower abdominal pain, vaginal bleeding, or both. Patients were excluded from the study if there was a history of recent surgery or major trauma. Data analysis included receiver operating characteristic (ROC) curve, 95% confidence intervals (CIs), and a regression model. RESULTS: A total of 378 patients were enrolled, with 61 patients diagnosed with an ectopic pregnancy, and 317 patients placed in the non-ectopic pregnancy group with other diagnoses. ROC curve analysis revealed an area under the curve of 0.56 (95% CI 0.51 to 0.61) for CPK, 0.63 (95% CI 0.59 to 0.68) for SMHC, and 0.58 (95% CI 0.53 to 0.63) for myoglobin. A regression model analyzing the effects of race, maternal age, estimated gestational age, and serum levels of human chorionic gonadotropin beta-subunit found no significant confounders. CONCLUSION: Although there is a statistically significant elevation in the serum levels of SMHC, the range of values seen is too large to allow SMHC to be a useful screening tool.

The utility of maternal creatine kinase in the evaluation of ectopic pregnancy.

This investigation was designed to evaluate the utility of maternal creatine phosphokinase (CPK) in predicting the presence of an ectopic pregnancy (EP) in an emergency department (ED) setting. Twenty-one patients with the diagnosis of EP were randomly matched (1:1) with pregnant patients who subsequently ruled-out for EP. Serum CPK values at presentation were compared between the groups using two-tailed ANOVA, odds ratio, and frequency tables were generated using our a priori hypothesis that a serum CPK of >70 mlU/dL may be useful as a predictor of EP. The mean serum CPK was 118mlU/dL in the EP group and 64 mlU/dL in the non-EP group (P < .0031). Controlling for age, race, and gestational age, there was an association between elevated serum CPK and EP in our study population (with an odds ratio of 6.5). The categorical evaluation (with 95% confidence interval [CI]) of CPK (>70 mIU/dL) as a predictor of EP follows: sensitivity - 100% (80.8 to 100); specificity-- 61.9% (38.7 to 81); PV(+) - 72.4% (52.5 to 88.6); PV(-) - 100% (71.7 to 100). We therefore conclude that a CPK level >70 mIU/dL may serve as an important adjuvant diagnostic tool in ruling-out EP.

Is maternal serum creatine kinase actually a marker for early diagnosis of ectopic pregnancy?

OBJECTIVE: Our purpose was to investigate whether serum creatine kinase (CK) levels could be used as an early marker of ectopic pregnancy. Student's t-test was used for statistical analysis. STUDY DESIGN: In a prospective study we therefore measured serum progesterone, beta hCG and CK levels in 30 women with ectopic pregnancies, 30 women with ongoing pregnancies and 30 women with missed abortion. RESULTS: The mean serum CK concentration for patients with an ectopic pregnancy, ongoing pregnancy, and the women with missed abortion was 81.4 +/- 66.2, 81.5 +/- 40.3, 84.8 +/- 49.3, respectively. No relationship was found between CK level and the location of the pregnancy. CONCLUSION: Conversely to the first report of Lavie et al. (Am J Obstet Gynecol 1993; 169: 1149), our data suggest that serum CK level is not discriminative in the early diagnosis of tubal pregnancy.

Serum amylase isoenzymes in ectopic pregnancy.

In general, significant amylase elevation was not documented in women with tubal pregnancies, compared with normal IUPs in the first trimester and a nonpregnant control range. One of 49 samples in 25 patients with tubal pregnancy was mildly elevated for salivary amylase.

[Placental lactogen level and activity of oxytocinase, beta-glucuronidase and thermostable alkaline phosphatase isoenzyme in blood serum of women with ectopic pregnancy]. / Poziom laktogenu lozyskowego oraz aktywnosc oksytocynazy, beta-glukuronidazy i termostabilnego izoenzymu fosfatazy alkalicznej w surowicy krwi kobiet z ciaza ektopowa.

The lack of literature data dealing with placental lactogen concentration as well as with the other biochemical parameters in blood serum in women with ectopic pregnancy was the reason we turned to that problem. In eight patients with ectopic pregnancy there was determined placental lactogen level and oxytocinase activity as well as the activity of beta-glucuronidase and thermostable alkali phosphatase isoenzyme in blood serum. The results obtained were compared to the concentration of those parameters in blood serum in women with ectopic pregnancy and to those of not pregnant women. It was stated that in women with ectopic pregnancy there was produced placental lactogen and its concentration in blood serum was lower (about 30 percent) than that in women with ectopic pregnancy. Similarly, mean value of oxytocinase activity in women with ectopic pregnancy was twice lower in comparison to that of ectopic pregnancy, while beta-glucuronidase activity was twice higher when compared to that of ectopic pregnancy values. Placental alkali phosphatase isoenzyme activity was similar in both groups of pregnant women.

Serum amylase levels in ectopic pregnancy.

Thirty-four women with abdominal complaints and a positive pregnancy test were evaluated for possible ectopic pregnancy (EP). Serum amylase levels were obtained as part of the diagnostic workup to note any correlation of enzyme levels with the presence of EP. Thirteen individuals (30%) were subsequently diagnosed as having an EP, and serum amylase levels in all of these patients were within normal limits, averaging 81 U/L. There was no statistically significant difference in amylase levels between the EP group and the non-EP group (P = .70). Serum amylase levels cannot reliably predict the presence of EP and should not be used as a screening or diagnostic test for this disorder.